Healthcare Provider Details

I. General information

NPI: 1477457026
Provider Name (Legal Business Name): SOPHIA GABRIELLA BANEZ OTD, OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 HACKMANN RD
SAINT CHARLES MO
63303-5452
US

IV. Provider business mailing address

7535 OXFORD DR APT 1E
SAINT LOUIS MO
63105-2891
US

V. Phone/Fax

Practice location:
  • Phone: 636-851-6200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number2025028396
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: